2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Otolaryngology–Head and Neck Surgery 148(6S)

the voice or the patient’s history of either having had a change in voice or generalized concerns with the voice. In cases where the patient/family or the physician notes a voice abnor- mality, it is recommended that a preoperative assessment of larynx and VF function be performed. Reduced movement of 1 vocal fold on preoperative examination of the patient with hoarseness suggests involvement of the RLN by the thyroid disease, which may prompt extra caution and evaluation. In the general population, 1% of patients (and 2.5% of patients over age 75) seek evaluation and care for dysphonia, with 3% of those eventually diagnosed with VF paresis or paralysis. 97 Among patients screened in primary care clinics for dysphonia, there was a point prevalence of 7.5% and a lifetime prevalence of 29.1%. 98 Incidence rates for vocal fold paresis or paralysis for patients with benign thyroid disease is approximately 1% 99 and for malignant thyroid disease is as high as 8% 99 in patients who have not undergone a prior thyroid, neck, or chest sur- gery. A series of 200 patients with benign cervical and subster- nal goiter showed that 3.5% presented with vocal fold paralysis. 100 Of 340 pre-thyroidectomy patients, VF motion abnormalities were found in 6.5%. 101 A finding of VF paralysis on preoperative examination strongly suggests the presence of invasive thyroid malignancy. In 1 study, the rate of preoperative VF paralysis in a series of patients with invasive thyroid malignancy was over 70% ver- sus 0.3% in the control group of patients with noninvasive thyroid disease. 102 The preoperative knowledge of invasive dis- ease allows for more robust surgical planning, more detailed pre- operative imaging, and more specific preoperative patient counseling. The NCCN guidelines describe preoperative VF paralysis as a “highly suspicious factor” for cancer and the need for surgery. Identification of preoperative VF paralysis is also impor- tant because surgical algorithms in the management of inva- sive disease involving the nerve incorporate the degree to which the nerve is functional. Thus, preoperative functional information obtained via laryngeal exam greatly aids in tar- geted management of the invaded nerve. 102,103 The Guideline Development Group emphasizes that examination of laryn- geal function both before (Statement 2A) and after (Statement 10) thyroid surgery is recommended . There is not enough evi- dence in the literature to make this either a strong recommen- dation or mandatory; however, there is no evidence against laryngeal examination. As stated previously, the preponder- ance of benefit over potential harm permits this key action statement to rise to the level of a recommendation. The members of the GDG felt, overall, that examination of all larynges preoperatively would be of benefit to both physi- cian and patient, as diagnosis of asymptomatic vocal cord paresis and paralysis can be beneficial. However, guidelines are based on available literature, and there is not enough lit- erature to support a recommendation for examining all laryn- ges preoperatively. There are no standardized laryngeal examination methods that will fit all patients. Some of this will depend on the resources and equipment available in the

may also suffice for this purpose. The health care provider should ensure that his or her smartphone, if used in this manner, is HIPAA compliant. The audio recording can be used postop- eratively to compare the patient’s voice to the preoperative recording to determine if changes in voice pitch, loudness, and quality are perceived. STATEMENT 2A. PREOPERATIVE LARYNGEAL ASSESSMENT OF THE IMPAIRED VOICE: The sur- geon should examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobil- ity, if the patient’s voice is impaired (as determined by the assessment in Statement 1) and a decision has been made to proceed with thyroid surgery. Recommendation based on observational studies with a preponderance of benefit over harm. Action Statement Profile • • Aggregate evidence quality: Grade C • • Benefit: Assess mobility of vocal fold, potential diagnosis of invasive thyroid cancer, influence the decision for surgery, extent of surgery, intraopera- tive technique, preoperative patient counseling, dis- tinguish iatrogenic from disease related paralysis/ paresis • • Risk, harm, cost: Misdiagnosis (false positive/false negative), cost of examination, patient discomfort, resources, access, anxiety • • Benefit-harm assessment: Preponderance of benefit • • Value judgments: None • • Role of patient preferences: Limited • • Exclusions: None • • Policy level: Recommendation Supporting text. The purpose of the statement is to improve quality of care by establishing baseline awareness of vocal fold mobility that may be important in perioperative manage- ment and outcome assessment. At present, only 6.1% to 54% of thyroidectomy patients undergo a preoperative laryngeal exam. 38,39,91 However, sev- eral international organizations are advocating for preopera- tive laryngeal exam. The BAETS and the German Association of Endocrine Surgery have recommended preoperative and postoperative laryngeal exam as requirements for all patients undergoing thyroid surgery. 92,93 The international neural mon- itoring study group recommends pre- and postoperative laryn- goscopy in all patients undergoing thyroid surgery with use of intraoperative neural monitoring (IONM). 94 Other groups offer less universal recommendations. The British Thyroid Association recommends laryngeal exam for preoperative patients with voice changes and for those undergoing surgery for cancer, and the National Comprehensive Cancer Network (NCCN) recommendations include preoperative laryngos- copy in all patients with thyroid malignancy. 95,96 The decision to proceed with an examination of the larynx is often predicated on the initial perception of the quality of

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